Yuriy Vladimirovich Shchukin

Aim . To develop a prognostic model for the probability of adverse cardiovascular events over three years in patients over 70 years of age with prior myocardial infarction (MI), frailty syndrome, and myocardial revascularization. Material and methods. This prospective study included 92 patients over 70 years of age with MI. Clinical and history data, the Charlson comorbidity index, general laboratory data, myocardial stress and fibrosis biomarkers (NT-proBNP and ST-2), and structural and functional cardiac parameters were assessed. The Age Is Not a Barrier questionnaire was used to identify frailty. The median follow-up period (Q1; Q3) was 1045 (367; 1099) days. An adverse cardiovascular event was chosen as the endpoint. Nonparametric statistical methods, Cox regression, and logistic regression were used. R e sults . The mean age of patients was 77,3±2,4 years. Using Cox regression, following 3-year predictors of adverse cardiovascular events were identified: age ≥80 years (p=0,001), prior MI (p=0,011), CKD-EPI glomerular filtration rate on admission ≤55 ml/min/1,73 m2 (p=0,008), and pulmonary artery systolic pressure ≥38 mm Hg (p=0,022), Simpson’s ejection fraction ≤45% (pConclusion . PCI in patients over 70 years of age with MI and frailty reduces the risk of adverse cardiovascular events over three years. Prediction of adverse cardiovascular events is possible based on the proposed prognostic model.

Highlights The severity of coronary atherosclerosis associated with a deterioration in the deformational properties of the myocardium, disturbances in microcirculation, as well as an increase in inflammatory and profibrotic biomarkers.  AbstractAim. To study the relationship between the severity of coronary atherosclerosis, endothelial dysfunction and myocardial fibrosis in patients with chronic heart failure who have had a myocardial infarction.Methods. 96 patients with chronic heart failure hospitalized in the acute period of myocardial infarction were included. All participants underwent: echocardiographic examination with assessment of left ventricular ejection fraction (LVEF) and global longitudinal strain, laser doppler flowmetry, assessment of biomarker levels (CRP, sST2, NTproBNP, VEGF), coronary angiography.Results. According to coronary angiography results, multivessel coronary artery disease was identified in 58 (60.4%) patients, and left main coronary artery (LMCA) involvement was found in 20 (20.8%). The severity of coronary atherosclerosis was associated with a decrease in LVEF (R = –0.31, p = 0.002), global longitudinal strain (R = –0.73, p < 0.001), amplitude-frequency parameters of microcirculation, volume of regulatory mechanisms, and coefficient of variation of microcirculation (R = –0.3, p = 0.003), as well as an increase in the degree of left ventricular diastolic dysfunction (R = 0.31, p = 0.002), capillary blood flow reserve (R = 0.29, p = 0.005), concentrations of CRP (R = 0.32, p = 0.002), NT-proBNP (R = 0.71, p < 0.001), and sST2 (R = 0.77, p < 0.001). Inverse relationships were identified between the number of affected coronary arteries and LVEF (R = –0.23; p = 0.027), coefficient of variation of microcirculation (R = –0.36, p < 0.001), and amplitude of microcirculation oscillations in the neurogenic range (R = –0.24, p = 0.019). Patients with LMCA stenosis had lower LVEF, amplitudes of oscillations in the neurogenic and myogenic ranges, as well as higher capillary blood flow reserve values.Conclusion. The results of the study indicate a relationship between the severity of coronary atherosclerosis and changes in hemodynamics at the microcirculatory level, fibrotic remodeling of the myocardium, and concentrations of biomarkers such as CRP, NT-proBNP, and sST2.

Aim – to determine the prognostic significance of global longitudinal strain of the left ventricle (GLS) and soluble stimulating growth factor (sST2) in patients with chronic heart failure (CHF) after myocardial infarction (MI) in the annual follow-up period. Material and methods. The study included 96 patients with CHF who were hospitalized with acute MI. All subjects underwent speckle-tracking echocardiography and determination of concentrations of sST2, vascular endothelial growth factor (VEGF), N-terminal pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP). After 12 months patients were assessed for cases of stroke, recurrent myocardial infarction, hospitalization for unstable angina or decompensation of CHF, and cardiovascular death, forming a combined endpoint (CEP). Results. The development of CEP was registered in 44 (45.8%) patients with initially lower left ventricular ejection fraction and GLS, higher left ventricular myocardial mass index, index of impaired local contractility, basal diameter of the excretory tract, as well as a higher score on the Syntax scale and concentrations of CRP, NT-proBNP and sST2. During the ROC-analysis for the development of CEP, optimal thresholds for sST2 and NT proBNP were determined, which were 36.1 ng/ml and 427 pg/ml, respectively. The multifactorial analysis made it possible to develop a mathematical model for predicting adverse outcomes within 12 months after MI, which included such indicators as GLS – odds ratio (OR) 0.51 (0.39; 0.72), the number of points on the Syntax scale – OR 3.05 (2.2; 6.8), concentrations of NTproBNP – OR 2.9 (1.45; 5.1) and sST2 – OR 3.3 (1.65; 7.51). Conclusion. The developed prognostic model includes factors reflecting various links in the pathogenesis of CHF, which provides an integrated approach to assessing the risks of recurrent cardiovascular events after MI.

Aim. To study real-world data on managing patients with coronary artery disease (CAD) and multifocal atherosclerosis (MFA) for 12 months by outpatient cardiologists.Material and methods. KAMMA is a real-world registry organized by the Eurasian Association of Therapists. The main branch included men and women over 18 years of age with confirmed atherosclerosis in two or more arterial systems and one or more risk factors for atherosclerosis. The start date for patient recruitment was February 1, 2022 and the end date was November 27, 2022. The design included 3 following visits: 1 — baseline, 2 — after 6 months, 3 — after 12 months. Twentyeight research centers were located in 7 federal districts of the Russian Federation, as well as in the Republics of Kazakhstan, Uzbekistan and Belarus.Results. A patient population (n=2905) was formed, all of whom had verified CAD. The mean age was 66,0 [59,0; 72,0] years (men — 60,3%). Low-density lipoprotein cholesterol decreased by 20,4% over 12 months, while non-high-density lipoprotein cholesterol — by 12,7%. Over 12 months, lipid-lowering therapy did not undergo significant changes. Statin monotherapy was maintained in 83%, of which only 53,7% of patients received high-dose therapy. Combined statin+ezetimibe therapy was used in 12,4%, while statin+ezetimibe+PCSK9 inhibitor — in 4,6%. During the 1-year follow-up, antithrombotic therapy was not enhanced. Low prescription rate of combination therapy with antiplatelet agents (15,7%) and low-dose rivaroxaban and acetylsalicylic acid (7,9%) remained. By the follow-up end, a high incidence of major adverse cardiovascular events (8,8%) was registered in patients included in the KAMMA registry.Conclusion. Despite the fact that patients with MFA have a very high cardiovascular risk, routine management of these patients is characterized by high clinical inertia. During the 1-year follow-up, lipid-lowering and antithrombotic therapy was not properly strengthened, due to which the target levels of key lipid profile parameters were not achieved and a high rate of major adverse cardiovascular events was observed in patients included in the registry.

Aim – to determine additional risks of developing arterial thrombotic and thromboembolic complications in bradysystolic AF and substantiate the results using modeling of intra-arterial hemodynamics. Material and methods. A single-center prospective study involving 252 patients: 146 in the main group, 106 in the control group. The main group was divided into 2 subgroups: 1A subgroup RR ECG interval 1.5 seconds; 2B subgroup RR≥1.5 seconds. A comprehensive examination of the patients was carried out. The second stage is prospective comprising an analysis of the development of arterial thrombotic and thromboembolic complications over 1 year. Experimental modeling was carried out using the “Device for simulating intra-arterial circulation”. Results. Thrombotic and thromboembolic complications were more common in subgroup 1B (OR=8.287 (2.287; 30.040); z=3.219; p=0.001). When analyzing the main parameters of the hemodynamics of the main arteries, the first pulse wave, coming after a long pause of 1.5 seconds or more in AF, was accompanied by a statistically significant increase in all of analyzed parameters. In the experiment, when simulating AF, the intensity of the mechanical impact of the free end of the thread on the wall of the rotameter was maximum when the pause between pulse waves was 1.5 seconds or more (9.70 ± 2.52 mm). At this moment, the piezocrystalline pressure sensor recorded the maximum increase in pressure inside the rotameter tube by an average of 56%. Conclusions. Bradysystole in AF is associated with a significantly higher likelihood of developing long-term thromboembolic events. The first pulse wave, coming after a long pause between ventricular contractions during AF, leads to a significant increase in the main parameters of the hemodynamics of the main arteries (linear velocity of blood flow, volumetric blood flow). When monitoring heart rate in AF, it is necessary to avoid bradysystole with pauses between ventricular contractions of 1.5 seconds or more, due to a higher risk of stroke, myocardial infarction, and distal arterial embolism in other vascular regions.

Aim. To create a score for predicting arterial events (myocardial infarctions, strokes, ischemic events in other arterial systems) in patients with extrasystole.Material and methods. The study included 740 patients (634 — the main group, 106 — control). The main group had 700 or more premature beats per day, and the control group had Results. At the first visit, the groups of patients were equivalent in comorbidities, prior events, data from additional research methods. However, a significantly higher prevalence of ischemic events within 1 year was revealed in subgroup II. The creation of an original Ex- PRO score for predicting long-term complications with premature beats ≥700 or more per day made it possible to predict ischemic events in this category of patients (prediction accuracy 87,1%).Conclusion. Extrasystole is an additional factor in the development of arterial events in various arterial systems. Ex- PRO includes the following parameters: type IIIB plaque according to extracranial Doppler ultrasound, extrasystole up to the peak transmitral flow ≥700 per day, hemodynamically insignificant carotid bifurcation stenosis according to extracranial Doppler ultrasound, female sex, impaired left ventricular local contractility, hemodynamically insignificant lower limb artery stenosis.

Aim. To study the clinical status and data of laboratory and instrumental examination of patients with non-obstructive ischemic heart disease (IHD) and multifocal atherosclerosis (MFA) included in the KAMMA registry. Material and methods. The subanalysis included 1,893 IHD patients who underwent coronary angiography (CAG) and ultrasonic examination of peripheral arteries. Based on the CAG data, patients were divided into two groups: group 1, patients with obstructive coronary atherosclerosis (CA) (maximum stenosis ≥50% and/or history of percutaneous coronary intervention/coronary artery bypass grafting, n=1728; 91.3%) and group 2, patients with non-obstructive CA (maximum stenosis Results. A comparative analysis based on the degree of coronary obstruction in patients with verified IHD who were included in the KAMMA registry showed that 8.7% of them had coronary artery stenosis of less than 50%. The overwhelming majority of patients with non-obstructive CA had MFA affecting the brachiocephalic arteries in 94.3% and the lower extremity arteries in 40.2%. Among patients with non-obstructive IHD, women predominated; risk factors such as smoking and type 2 diabetes mellitus were less frequent in this group than in the obstructive IHD group. Patients with non-obstructive CA more frequently had a history of dyslipidemia; they had higher total cholesterol and non-high-density lipoprotein cholesterol; and they more frequently received moderate-intensity statin therapy than patients with obstructive CA (55.8% vs. 34.5%). Characteristic features of patients with non-obstructive CA were less severe IHD and less frequent history of acute coronary syndrome. However, the incidence of stroke, peripheral arterial thrombosis, and chronic arterial insufficiency of the lower extremities did not differ in groups 1 and 2, whereas the incidence of paroxysmal atrial fibrillation was higher in the non-obstructive IHD group. Conclusion. IHD patients without coronary obstruction also require assessment of the peripheral arterial status, as they may have advanced MFA, which should be taken into account when choosing the “aggressiveness” of therapy.

Aim. To investigate the prevalence and characteristics of polyvascular disease in the Eurasian region's population with one or more previously established locations of atherosclerotic arterial damage, and to evaluate the diagnostic importance of the ankle-brachial index (ABI) as a marker for polyvascular disease (PVD).Material and methods. A total of 1837 patients were included in the main branch of the KAMMA registry (patients with PVD), among which 91,6% had coronary artery disease (CAD) (n=1683). For further analysis, the group of patients with CAD was combined with 1222 patients included in the second branch of the registry — KAMMA-cardio, forming a patient population (n=2905), in which all patients had verified CAD. The mean age of patients was 66,0 [59,0; 72,0] years, with 60,3% being male. Peripheral arteries was assessed using ultrasound examination.Results. PVD was present in 95,6% of patients with coronary atherosclerosis: dual-region involvement was observed in 51,3% of patients, three-region involvement in 37,1%, four-region involvement in 3,4%, and five-region involvement in 2,0%. Stenoses of the common carotid artery were observed in 71% of patients, internal carotid artery — in 68%, lower limb artery — in 52%, and renal and mesenteric artery — in 8,3%. There were following diagnostic effectiveness of the ABI for detecting patients with lower limb artery stenosis was: sensitivity — 58,0%, specificity — 83,6%. The quality of antithrombotic and lipid-lowering therapy was insufficient.Conclusion. In the overwhelming majority (95,6%) of patients with CAD in the KAMMA registry, PVD was revealed, with nearly half of the patients having involvement in three or more arterial zones. In the patient population with CAD, there should be an active effort to identify patients with PVD, using at least the ABI determination and active modern antithrombotic and lipid-lowering therapy according to current clinical guidelines.

Aim. To develop a predictive model of the risk of adverse outcomes within 12 months after myocardial infarction (MI) in patients over 70 years of age with frailty syndrome.Material and methods. This prospective observational study included 92 patients over 70 years of age with MI who were treated in the cardiology departments of Samara State Medical University Clinics from 2020 to 2021. Levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth stimulation expressed gene 2 (ST2) were determined in serum by enzyme-linked immunosorbent assay on day 5 of hospitalization. Frailty syndrome was identified 5th day of hospitalization using "Age is not a hindrance" questionnaire. The observation period was 12 months. The end point was the adverse event occurrence (all-cause death, cardiovascular death, recurrent MI, cerebrovascular accident). Statistical nonparametric methods, correlation analysis, ROC analysis, and logistic regression were used.Results. There are following significant predictors of unfavorable outcome within 12 months after MI in patients over 70 years: age over 80 years (odds ratio (OR) 5,57, 95% confidence interval (CI) 2,07-14,96, with p=0,001), history of MI (OR 3,96, 95% CI 1,36-10,26, at p2 (OR 4,05, 95% CI 1,55-10,57, with p=0,004), pulmonary artery systolic pressure above 38 mm Hg (OR 4,5, 95% CI 1,69-11,96, with p=0,003), Simpson's left ventricular ejection fraction Conclusion. Prediction of an unfavorable outcome based on the "Age is not a hindrance" questionnaire score, Simpson's left ventricular ejection fraction in %, and ST2 concentration can improve risk stratification for adverse outcomes within 12 months after MI in patients over 70 years.

Aim. This study aims to investigate the effect of senile asthenia syndrome (SAS) on the cardiovascular mortality risk within 12 months in patients over 70 years of age with myocardial infarction.Material and methods. We performed a retrospective study of 92 patients over 70 years of age with myocardial infarction, who agreed to participate. To detect senile asthenia syndrome, we used the questionnaire "Age is not a hindrance". We estimated the anamnestic data, and also laboratory and instrumental parameters. The follow-up period was 12 months. As an end-point, the onset of an adverse event — cardiovascular death was chosen. Statistical nonparametric methods, ROC analysis, Kaplan-Meier survival analysis (pResults. In 12 months, 19 patients (20,65%) met the end-point. The median (25%; 75%-quartile) of the numbers of points according to the questionnaire "Age is not a hindrance" was significantly higher in the group of dead patients than in the group without adverse outcomes — 4 (3; 5) and 2 (1; 4) points (pConclusion. The risk of cardiovascular death within 12 months after myocardial infarction in patients over 70 years of age with SAS increases by 72%. The inclusion of the results from the questionnaire "Age is not a hindrance" into prognostic models, and the SAS estimation in this cohort of patients will improve the risk stratification.